Trauma and complex procedures
At the end of this chapter you should have a clear understanding of:
- 1. Trauma.
- 2. Temporomandibular joint disorder.
- 3. Salivary gland surgery.
- 4. Craniofacial and oral cancer.
- 5. Cleft lip and palate.
- 6. Bisphosphonate-related osteonecrosis of the jaw (BRONJ).
- 7. Anticoagulant therapy.
- 8. Orthognathic surgery.
- 9. Dental implants.
- 10. Tongue-tie release.
- 11. Apicectomy.
- 12. Avulsion.
- 13. Alveolectomy.
- 14. The role of the dental nurse during complex procedures.
Frequently, the maxillofacial outpatient team will be requested to assess and treat patients who have suffered trauma to the face, head or neck. There is a wide spectrum of severity of injuries that may be encountered ranging from cuts, bruising and bites to complex lacerations, fractures and high-velocity injuries. Factors and situations that may be associated with traumatic injuries are alcohol consumption and associated behaviour, sports injuries, falls and disease.
Patients who have suffered traumatic injuries will usually be referred to the maxillofacial department by either accident and emergency (A&E), medical assessment unit (MAU) or a hospital ward. Prior to this referral, initial assessment and stabilisation of the patient’s overall condition will have been carried out. This may include:
- • Airway, breathing and circulation assessment (ABC).
- • Initial assessment of injuries, including possible head injury.
- • Assessment and treatment of other injuries.
- • Imagery (radiographs, CT and MRI scans).
- • Pain control.
- • Prophylaxis antibiotics.
Once the referral has been received by the maxillofacial department, the patient will be assessed by a team member who will then either treat the patient if the injury is within their scope of practice or, if needed, refer to a consultant maxillofacial surgeon.
Trauma such as a fall, assault, sporting or road traffic accident (RTA) may cause injury to the facial bones. Fractures caused by a trauma are classified as simple, compound or comminuted:
- • Simple: There are several types of simple fractures; however, in all cases the fractured bone does not penetrate the skin.
- • Compound: The fractured bone penetrates the surrounding tissues and skin and is exposed to the external environment.
- • Comminuted: With a comminuted fracture the bone fractures into several fragments.
Fractures of the mandible
Fractures of the mandible, caused by trauma to the lower face, are frequently seen within the maxillofacial department. Mandibular fractures may be unilateral (affecting one side), bilateral (affecting both sides) or multiple. These fractures are classified (Figure 7.1) as being:
- • Condylar: a fracture of the condyle, either unilateral or bilateral.
- • Coronoid: a fracture of the coronoid process which will usually involve fractures to other neighbouring structures.
- • Angle: a fracture where separation of the ramus and body occurs.
- • Ramus: a fracture between the angle of the mandible and the condylar area.
- • Body: a fracture between the angle and the parasymphyseal.
- • Symphyseal: a mid-line fracture.
- • Parasymphyseal: a vertical fracture in the region of the lower canine area.
- • Dentoalveolar: a fracture of the alveolar bone.
Fractures of the mid-face
Fractures involving the mid-face region (Figure 7.2) are categorised as:
- • Le Fort I: A horizontal fracture above the maxillary teeth. This fracture in effect separates the upper jaw from the face and is sometimes referred to as a ‘floating palate’.
- • Le Fort II: A pyramid-shaped fracture involving the orbital rims and nose.
- • Le Fort III: A high-level horizontal fracture which traverses through several structures including the orbits, ethmoid and zygomatic arches. This complex fracture separates the whole of the mid-face from the cranium.
Injury to the mid-face may result in a fracture to the zygomatic process. This injury is usually attributed to a form of blunt trauma such as an assault. Fractures to this area involve the orbit. Fractures to the orbital floor are sometimes referred to as an ‘orbital blow-out’. As with any fracture there are different levels of severity. Simple fractures which are non-displaced may heal uneventfully. More complex fractures which are displaced, or if tissue from surrounding structures is entrapped, may require surgical intervention.
Patients presenting with this injury may complain of double vision (diplopia). There may also be a flattening of the face in the cheekbone area; however, due to swelling following injury this may not be initially noticeable.
All bone fractures need time to heal and this usually involves some form of immobilisation. For fractures of the face this can be challenging. Some fractures which are un-displaced may be suitable for conservative treatment. This would involve a prescribed period of eating soft food, rest, analgesics, good oral hygiene and refraining from contact sports. Some unilateral condylar fractures may be suitable for this form of treatment.
Should the fracture be displaced or complex, the maxillofacial surgeon will aim to realign, restore and maintain alignment of the fracture. This is referred to as reduction and fixation.
Inter-maxillary fixation (IMF)
This is a form of indirect fixation and may be suitable for some simple fractures. IMF uses arch bars and wires to secure the upper and lower jaws together. IMF aims to maintain the patient’s occlusion, thus immobilising the fracture indirectly. Although IMF treatment alone does avoid the need for an open surgical procedure, it is not without its own disadvantages. IMF prolongs the patient’s convalescence, and the patient will only be able to eat a liquid or semi-liquid diet for a number of weeks. It is also likely that, due to the nature of IMF, the individual’s oral hygiene will deteriorate during treatment as they will not be able to clean sufficiently well.
Open reduction and internal fixation (ORIF)
When reduction and stabilisation of the fracture is needed, direct fixation may be necessary. Intervention known as ORIF (Figure 7.3) will be performed. This is a surgical procedure performed by the surgeon in theatre with the patient under general anaesthesia. Exposure to the fracture site is usually gained intra-orally; however, there may be a requirement for an external incision. The fracture will be reduced and fixed into a stable position with plates, screws and wires. The patient may in some cases require IMF. Upon discharge analgesics will be prescribed and the patient will be advised of the recommended post-operative instructions, which may be similar to those given for conservative treatment.
Soft tissue injuries which may be treated within the maxillofacial department may include lacerations, bites, bruising and haematomas involving the head, face or neck. Following initial assessment and stabilisation, patients may be referred to the maxillofacial surgeon for definitive treatment. It is important to remember that the patient may require much reassurance as they may be quite understandably concerned and distressed.
Lacerations and bites
Lacerations and bites can vary in size and severity. Some may appear initially superficial, but careful examination may disclose complications such as a deep shelf laceration and ‘through-and-through’ wounds which may involve underlying blood vessels, nerves and muscles. Lacerations and bites to the face may involve anatomical boundaries such as around the lip and eye which will require precise realignment during its repair. Through-and-through lacerations (Figure 7.4) penetrate skin and tissue through to the mucosa of the mouth.
Before definitive closure of the injury is performed, thorough cleaning and debridement of the area to remove possible debris is essential. Sterile solution is used to irrigate the wound and any visible debris and foreign objects must be carefully removed by the clinician; this will prevent tattooing once healing has occurred. Gentle scrubbing using a soft bristled brush such as a toothbrush may also be used.
Once the area has been thoroughly cleaned, absorbable sutures are placed in the deeper tissue first. These sutures bring the involved deeper tissues together, aiding healing. Following this, monofilament, non-absorbable sterile sutures are placed in the skin to completely close the wound. The clinician may place a dressing over the area; this is not always necessary, however. An antibacterial ointment may also be prescribed for the patient to apply as directed. As the sutures are non-absorbable, the patient will need to attend a follow-up appointment for these to be removed. This will also provide a good opportunity for healing to be monitored.
Bruising is caused by ruptured capillaries leaking blood into the tissues which form the skin.
This bleeding causes the characteristic purple, black and blue skin discolouration. This may also be accompanied by tenderness and pain. The discolouration gradually reduces, with the colour becoming green or yellow before completely resolving in around 2 weeks.
Usually caused by blunt trauma, a haematoma is a confined collection of clotted blood.
Most haematomas heal uneventfully; however, some may require treatment to prevent long-term disfigurement and resulting scar tissue, particularly those involving the face and head. Patients may be advised to regularly massage the affected area to help break down the clot and hopefully prevent the formation of scar tissue. Prompt treatment may be required for those haematomas involving the ear or nose. Treatment would involve incision and drainage of the haematoma followed by a compression dressing. Untreated ear haematomas may lead to disfigurement of the ear resulting from the collected clotted blood separating the cartilage from other tissues and vessels. In untreated cases this tissue separation causes the cartilage to die. This results in the area becoming pale and shrivelled. In addition to this fibrous scar tissue also forms over time, resulting in the characteristic ‘cauliflower ear’ (a condition which frequently affects boxers and rugby players).
This term is used to describe a dysfunction of the temporomandibular joint (TMJ) and its associated muscles. Rather than arthritis, TMJD is usually a muscular condition caused by overloading the muscles of mastication. In the majority of cases, TMJD responds well to conservative treatment. For some individuals the symptoms of TMJD can be painful and distressing, resulting in a negative impact on their quality of life. The symptoms of TMJD can include crepitus which is a clicking, grating or popping noise from the joint area caused by the cartilage disc within the joint moving slightly out of position. Symptoms may also include chronic pain, limited mouth opening and the feeling that the joint is locked.
During the patient’s assessment, consent and a detailed history of the symptoms will be taken followed by an intra- and extra-oral examination. The maxillofacial surgeon will usually palpate the joint area and associated muscles while asking the patient to open and close their mouth. The clinician may also utilise a disposable paper range-of-motion scale (Figure 7.5) to accurately measure the patient’s mouth opening. Should it be necessary, medical imagining of the TMJ (Figure 7.6) may be requested.
Patients should be reassured that symptoms of TMJD usually respond well to joint rest, conservative treatment and lifestyle changes. Advice given may include:
- • Avoid wide mouth opening such as yawning or when eating.
- • Soft diet: refrain from hard or chewy foods.
- • Be aware of and avoid parafunction habits, for example nail biting and pen chewing.
- • Grinding and clenching, particularly during sleep, can cause significant TMJD symptoms and may be an indication of stress in the individual’s life which may need to be addressed.
- • Gentle tongue and jaw exercises performed regularly as directed by the clinician.
- • The application of gentle heat to the affected area, such as a warm water bottle or heated, folded towel.
- • The use of paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) under the direction of the clinician may also be recommended.
A small number of patients may require further investigation or treatment such as arthrocentesis or arthroscopy.
Arthrocentesis is a surgical procedure in which sterile fluid is used to wash out the TMJ with an aim of returning the cartilage disc to the correct position and removing any debris from inside the joint. Arthrocentesis is performed while the patient is asleep under general anaesthetic. Local anaesthetic is administered to the TMJ site and two needles are inserted in front of the ear into the joint. Sterile fluid is passed under pressure through one needle and allowed to flow out of the second. During the procedure, the maxillofacial surgeon may manipulate the patient’s jaw in an attempt to realign the cartilage disc. At the end of the procedure the surgeon may administer a steroid drug directly into the joint. Arthrocentesis can also be performed during an arthroscopic examination.
An arthroscope is used to examine inside joints and is used for diagnostic and sometimes surgical procedures such as removal of scar tissue. It is a small camera/telescope that projects an imagine onto a connected monitor. Arthroscopies are sometimes referred to as keyhole surgery. As with arthrocentesis, it is performed with the patient under a general anaesthetic. Following the administration of local anaesthetic, a small incision is made in front of the ear. The arthroscope is inserted through the incision into the jaw joint. Should the maxillofacial surgeon require other instruments, a second incision is made to facilitate their use.
A patient who presents with an unexplained swelling or lump relating to a salivary gland will be referred to a maxillofacial surgeon for investigation.
Also known as salivary calculi or salivary stones, sialolithiasis (Figure 7.7) are calcified masses which form in the salivary glands and ducts. They can vary in size from a few millimetres to several centimetres. Usually affecting the submandibular duct, the calculi can cause either a partial or complete obstruction of the duct. Symptoms may include a history of recurrent pain and swelling, particularly when salivary flow is stimulated at mealtimes, a lump intra-orally in the region of a salivary duct, and also hyposalivation. Diagnosis of sialolithiasis may require radiographic examination. Calculi affecting the submandibular duct may be visible on plain film radiographs. Should the suspected stone not be visible, then imagining by sialogram may be requested. CT or MRI scans may also be considered.
A sialogram (Figure 7.8) is a type of radiograph which uses a contrast dye to aid diagnosis of sialolithiasis and other possible salivary conditions. Prior to the radiograph a cannula is inserted into the identified duct and a contrast medium is injected via the cannula into the duct. The dye will aid the visibility of the duct on the produced image.
Some small salivary calculi may resolve spontaneously if the stone passes out of the duct and into the mouth. However, removal of larger stones is frequently necessary. If upon examination the position of the stone within the duct is identifiable, surgical removal may be performed under local anaesthesia. This would involve a small incision in the area of the stone. Once the stone has been successfully removed, the incision may be left unsutured to heal. Other methods of removal may require an endoscopic procedure known as a sialendoscopy.
A small endoscope is inserted through the identified duct towards the salivary gland. This procedure may be performed under either local or general anaesthesia. Sialendoscopy may be used for diagnosis or therapeutic treatment. Instruments can be passed through the endoscope to treat blockages to the duct and remove calculi.
Parotidectomy is a surgical procedure to remove all or part of the parotid gland. During this procedure, an incision is made in front of the ear extending down into the neck. A flap is then raised to expose the parotid gland. The facial nerve runs through the gland and needs to identified and protected in an attempt to prevent its damage. In some cases the facial nerve may become damaged; if it forms part of the malignancy, it may need to be removed. An attempt to repair branches of the facial nerve which have been divided may be made with grafts from the great auricular nerve. Permanent facial weakness and palsy may result from damage to the facial nerve. In all cases, the earlobe is likely to remain numb after other areas have recovered.
Tumours affecting the salivary glands
- • Benign tumours: The majority of salivary gland tumours are benign including pleomorphic adenomas and Warthin’s tumour. The most common of these is pleomorphic adenoma. This tumour is a low-grade, slow-growing tumour.
- • Malignant tumours: There are several types of malignancy, some of which are very rare, which can affect the salivary glands. The majority of malignant tumours develop in the parotid gland. The main groups of malignant tumour are mucoepidermoid carcinoma, adenoidcystic carcinoma and adenocarcinoma.
- • Mucoepidermoid carcinoma: This is a cancer of the cells which line the salivary gland. It forms as small cysts. It is usually low grade and slow growing, although it can be high grade. Mucoepidermoid tumours usually develop in the parotid gland; however, they can on occasion develop in the submandibular and minor salivary glands.
- • Adenoidcystic tumours: These types of tumours are uncommon. They present in the mouth or on the face as a painless slow-growing mass.
- • Actinic cell adenocarcinoma: This type of tumour is usually slow growing and is most likely to affect the parotid gland.
The maxillofacial surgeon may arrange for diagnosis of the presenting mass by biopsy and fine needle aspiration, therefore allowing for a histology report. Medical scans may also be requested at this time. These investigations are described further in Chapter 6.
Cancer is when specific cells reproduce abnormally and uncontrollably. These abnormal cells can, in some instances, spread to surrounding healthy organs and tissue. The type of cancer which can spread is referred to as malignant. Not all cancers spread. This type of non- malignant tumour is known as benign. Maxillofacial surgeons diagnose and treat cancer of the head, neck and mouth. This includes cancer involving the skin, salivary glands, oral cavity and oropharynx. Areas of the oral cavity include:
- • Lips.
- • The gingiva and mucosa.
- • Floor of the mouth.
- • The hard palate.
- • Anterior two-thirds of the tongue.
Areas of the oropharynx include:
- • The posterior third of the tongue.
- • The soft palate.
- • The tonsils.
- • The posterior wall of the throat.
There are definite risk factors which increase the chance of developing cancer of these structures. Smoking and alcohol consumption are the main risk factors for cancer of the oral cavity and oropharynx. Exposure to ultraviolet light (UV) through sunlight or by using